Callback Program Research Articles

Piloting an opioid callback program in community pharmacies

BackgroundAlthough opioid prescribing has recently trended downward, opioid-related overdoses and deaths have drastically increased. Community pharmacists are accessible health care providers who are well positioned to disseminate information on opioid safety and to educate and counsel on medication use, managing adverse events, and proper medication disposal. Patient callbacks facilitate appropriate medication usage. We developed an opioid callback program that provides a framework for pharmacists to follow up with patients with an opioid prescription. ObjectivesThis study aimed to (1) describe the development of the opioid callback initiative and (2) report results from a pilot test in 2 community pharmacies. MethodsThe opioid callback process and data collection forms were collaboratively developed with community pharmacists at each site. Data recorded on the opioid callback forms were descriptively analyzed and chi-square test of independence explored differences by pain durations related to opioid disposal, security, and safety. Participating pharmacy staff were interviewed to identify facilitators and barriers to implementation, as well as opportunities for improvement. ResultsForty-one opioid callbacks were attempted and 36 were completed (87.8%). Pharmacists were statistically significantly more likely to discuss naloxone with patients with chronic pain (89.5%) than those with acute pain (46.2%). Pharmacists reported that the program successfully raised awareness of opioid disposal opportunities and safe opioid practices, including storage and naloxone ownership. They expressed patients’ willingness to answer questions and appreciation for the extra attention and care. ConclusionCommunity pharmacists are well positioned to address the opioid crisis as access points for medication questions, opioid safety education, opioid disposal, naloxone, and medications for people with an opioid use disorder. This study presents a proof of concept for a pharmacist-led opioid callback program. Expansion could help inform patients about how to use opioids safely, how to treat an opioid overdose, and where to dispose of unused medications.

Association of a Callback Program With Emergency Department Revisit Rates Among Patients Seeking Emergency Care

The emergency department (ED) discharge process often involves haste and poor communication. To assess the association of an automated telephone call 2 days after ED discharge with the likelihood of an unplanned ED revisit at both 72 hours and 7 days after the index visit and with perceived care metrics measured at 14 days. This prospective nonrandomized clinical trial was conducted at a single academically affiliated county emergency department among 8110 patients presenting to and discharged from the ED during a 10-week period from June 25 to August 30, 2018. Initial statistical analysis was performed from February 1 to November 30, 2020, with additional analyses performed from March 1 to 16, 2022. Participants were allocated in a nonrandom fashion to 1 of 2 groups: patients who received an automated telephone call 2 days after discharge were compared with patients who received no call 2 days after discharge. All patients received a telephone questionnaire at 14 days to assess secondary outcome measures. The primary outcome was a return visit to the ED at 7 days. Secondary outcomes included a return visit to the ED within 72 hours, a return visit to the ED within 7 days resulting in hospital admission, and patient-reported perceptions of their care measured by 4 questions related to quality metrics assessed at 14 days. A secondary analysis compared patients who actually responded to the initial call at 2 days with all nonresponders, regardless of whether they received a call. Analyses were made on an intention-to-treat basis. More than 15 000 patients were seen in the ED during the 10-week study period, and 10 948 were discharged. A total of 8110 patient encounters (4460 male patients [55.0%]; 3313 Hispanic patients [40.9%]; mean [SD] age, 40.5 [19.4] years) were enrolled. A total of 2958 patients (36.5%) received an automated telephone call at 2 days after discharge, while 5152 (63.5%) received no call. Rates of ED return within 7 days of the initial index visit were significantly lower among those who received a call at 2 days than those who did not receive a call (224 of 2958 [7.6%] vs 533 of 5152 [10.3%]; P < .001). Patients who received a 2-day call were more likely than those who did not receive a call to have followed up with a health care clinician (67.9% [374 of 551] vs 66.3% [604 of 911]), understood their health issues (77.5% [490 of 632] vs 74.9% [780 of 1042]), and have received their discharge medications (87.0% [507 of 583] vs 83.6% [793 of 949]), although none of these differences between the 2 groups were statistically significant. A telephone call to patients 2 days after discharge from the ED was associated with decreased ED use at 7 days after the index visit and may have been associated with marginal improvements in measured quality of care metrics.

Afrocentric screening program for breast, colorectal, and cervical cancer among immigrant patients in Ontario.

Black and immigrant populations across Canada have lower screening rates than Canadian-born white populations, predisposing them to increased cancer morbidity and mortality. Effective interventions are required to increase cancer screening rates among these populations. To improve breast, colorectal, and cervical cancer screening rates at TAIBU Community Health Centre, which has a mandate to provide primary health care services to the Black and immigrant community in the greater Toronto area. An Afrocentric quality improvement program was developed and implemented, consisting of provider audits, cancer screening education programs, a patient call-back program, and a mammography promotion day. TAIBU Community Health Centre's continuous quality improvement approach was successful in engaging health care providers and patients to increase cancer screening participation sustainably in a racially and socioeconomically diverse setting. Rates of breast, colorectal, and cervical cancer screening offered to eligible patients increased from 17% to 72%, 18% to 67%, and 59% to 70%, respectively, between 2011 and 2018.

Evaluating the Addition of a Clinical Pharmacist Service to a Midlevel Provider-Driven Culture Follow-up Program in a Community Emergency Department.

Background: The impact that an antimicrobial stewardship program can have on an inpatient setting has been well documented, but there are limited data on the use of an antimicrobial stewardship program in the emergency department (ED). Objective: The objective of this study was to assess the impact of adding a pharmacist service to a midlevel provider-driven culture follow-up program in the ED on achieving optimal therapy. Methods: This was a quasi-experimental study with designations of pre- and post-interventions conducted at a large community hospital with the pre-intervention phase occurring from June 1, 2019, to August 31, 2019, and the post-intervention phase occurring from January 1, 2020, to March 31, 2020. The primary outcome was optimal antimicrobial therapy: a composite of optimal antibiotic, dose, and duration, prescribed after the culture resulted. Secondary outcomes included optimal antibiotic, dose, duration, and return to the ED within 30 days due to infection. Results: Optimal antimicrobial therapy received after the culture resulted occurred in 59 patients (26.81%) in the pre-implementation phase and 40 patients (43.96%) in the implementation phase (P = .003). For the secondary outcomes, optimal antibiotic choice occurred in 115 patients (52.27%) in the pre-implementation phase and 66 patients (72.53%) in the implementation phase (P = .001). Optimal antibiotic dose occurred in 113 patients (51.36%) in the pre-implementation phase and 65 patients (71.43%) in the implementation phase (P = .001). Optimal antibiotic duration occurred in 65 patients (29.55%) in the pre-implementation phase and 40 patients (43.96%) in the implementation phase (P = .014). Conclusions: The addition of a clinical pharmacist service in a midlevel provider-driven ED culture callback program resulted in an increased rate of achieving optimal antimicrobial therapy.

Nurse-Led Call Back Program to Improve Patient Follow-Up With Providers After Discharge From the Emergency Department.

Phone calls to patients after discharge from the emergency department (ED) serve as reminders to schedule medical follow-up, support adherence to discharge instructions, and reduce revisits to already-crowded EDs. An existing, nurse-administered, call-back program contacted randomly selected ED patients 24 to 48 hours following discharge. This program did not improve patient follow-up (48.68%) nor reduce the ED revisit rate (6.7% baseline vs 6.0% postimplementation). Plan-Do-Study-Act methodology tested a modification to the existing program consisting of a second, scripted phone call from a trained volunteer at 72 to 96 hours postdischarge. Volunteers utilized a patient list and script, and nurses provided expertise to eliminate identified barriers to follow-up. Follow-up rate and ED revisit were monitored through the electronic medical record. A total of 894 patients participated between October 2017 and June 2018. Follow-up increased from 48.68% to 65.5% (P < .0001) and ED revisit decreased significantly (4.5% vs 8.6%, P < .001). This innovative nurse-led, systematic postdischarge call-back program utilizing hospital volunteers increased patient compliance with post-ED medical follow-up while significantly reducing the rate of patient revisit to the ED within 7 days of discharge.

Decreasing Trauma Readmission Rates by Implementing a Callback Program.

Decreasing hospital lengths of stay increases the burden on trauma patients after discharge. Our hypothesis was that a discharge callback protocol would decrease readmission rates. A retrospective quality improvement study evaluated all trauma patients admitted from 2012 to 2016 at a Level I trauma center. A postdischarge callback protocol was implemented in 2014, with a mature protocol in place in 2015. The precall and callback groups were compared regarding demographics, injury severity, and trauma readmission. Callback data included length of call, unsolicited patient comments, and education provided. Chi-square and Fisher's exact tests were used to compare categorical variables, whereas an independent-samples t test was used to compare continuous data. The precall program group included 4,470 admissions, and the call program group included 4,647 admissions. The precall program group had a higher injury severity score (ISS; 11.7 vs. 10.3; p < .001) and fewer males (62% vs. 65%, p = .002). In the call program group, there was a significant decrease in readmission rates (1.42% vs. 0.81%; p = .04). Patients with an unplanned readmission had a higher ISS (14.9 vs. 11.0, p < .01), a longer mean hospital length of stay during initial admission (9.3 days vs. 4.8 days, p < .01), and were more often discharged to locations with medical oversight (37.4% vs. 26.7%, p = .03). Of the patients in the call program group, 27.9% were reached. An average of 5.8 ± 2.9 min per call was calculated, equating to a 0.2 full-time equivalent. A discharge callback program for approximately 2,500 trauma patients per year leads to fewer readmissions, which financially supports the callback position.

Calling on the Patient's Perspective in Emergency Medicine: Analysis of 1 Year of a Patient Callback Program.

Background:Patient-centered approaches in the evaluation of patient experience are increasingly important priorities for quality improvement in health-care delivery. Our objective was to investigate common themes in patient-reported data to better understand areas for improvement in the emergency department (ED) experience.Methods:A large urban, tertiary-care ED conducted phone interviews with 2607 patients who visited the ED during 2015. Patients were asked to identify one area that would have significantly improved their visit. Transcripts were analyzed using content analysis, and the results were summarized with descriptive statistics.Results:The most commonly cited themes for improvement in the patient experience were wait time (49.4%) and communication (14.6%). Related, but more nuanced, themes emerged around the perception of ED crowding and compassionate care as additional important contributors to the patient experience. Other frequently cited factors contributing to a negative experience were the discharge process and inability to complete follow-up plan (8.0%), environmental factors (7.9%), perceived competency of providers in the evaluation or treatment (7.4%), and pain management (7.4%).Conclusions:Wait times and perceptions of ED crowding, as well as provider communication and compassionate care, are significant factors identified by patients that affect their ED experience.

219 Evaluation of an Enterprise-Wide Pharmacist-Driven Emergency Department Culture Callback and Antimicrobial Management Program

A culture callback (CCB) program is a systematic follow-up process to ensure that ED cultures, empiric antimicrobials, and laboratory studies are appropriately managed post discharge. Studies have shown that pharmacist-driven as opposed to nurse or clinician CCB programs result in an increased number of interventions made post-discharge and a decreased time to make the interventions. This study aims to provide a comprehensive assessment of the pharmacist-driven CCB process in a large integrated health system. A multi-center, retrospective review of 13 EDs (urban, suburban, community, and academic) within a health-system was conducted. Patients were included if they had a laboratory study drawn from the ED from December 1, 2017 to April 30, 2018 that did not result while the patient was in the ED and the patient was subsequently discharged from the ED. Microbiology results analyzed were urine, wound, respiratory, stool, throat, bacterial vaginosis, vaginal candidiasis, and sexually transmitted infections. These results were sent to a shared inbasket. Examples of non-microbiology results included drug screens, metabolic panels, and point-of-care testing. Pharmacists assessed non-microbiology results, which are forwarded to physicians for follow-up as needed whereas microbiology results are assessed and treatment changes are discussed with the emergency physician and patient. The primary objective was to quantify the number of interventions made by a pharmacist. Secondary objectives include quantification of results reviewed, characterization of intervention types, and time to intervention. Of the 226,884 patients who presented to the ED over this 5-month time period, pharmacists reviewed 5,452 non-microbiology results and 7,899 microbiology results for 11,194 patients. A large proportion of the cultures were urine (3,694, 46.8%), followed by gonorrhea/chlamydia (735, 9.3%) and throat (678, 8.9%). Of 6,303 encounters, 39.1% required interventions and/or follow-up. The most common interventions were initiation of therapy, change in medication, and follow-up with a provider (Table). Pharmacists were able to review culture results and complete interventions in a median of 25.2 hours. These results suggest that pharmacists are able to make impactful interventions on patient care post-discharge from the ED in a timely manner. Almost 40% of encounters required an intervention after discharge, indicating the need for stewardship initiatives in the ED.TableInterventionsInterventionsN = 2466Initiate therapy1345 (54.5%)Discontinue therapy239 (9.7%)Change medication389 (15.8%)Change dose66 (2.7%)Change duration40 (1.6%)Follow up with provider246 (10%)Return to the ED141 (5.7%)Data presented as number (%) Open table in a new tab

Growing a Geriatric Emergency Department

The concept of the geriatric emergency department is well developed after more than a decade of evolution, and at least nine EDs throughout the country are now accredited by the American College of Emergency Physicians (ACEP) as part of the first wave of geriatric ED accreditations. At AMDA – the Society for Post-Acute and Long-Term Care Medicine’s Annual Conference, the medical director of one of these departments, Marianna Karounos, DO, described the geriatric-focused policies and protocols, quality initiatives, staff education, and operational changes that her geriatric ED has embraced since it launched in 2009. In an interview after the meeting, she told Caring that her institution, St. Joseph’s University Medical Center in Paterson, NJ, has seen significant decreases in returns to the ED and in hospital admissions as a result. The “physical plant” of the geriatric ED should focus on structural changes that promote a quieter, safer, and less chaotic environment: non-slip, non-glare flooring, for instance, as well as uncluttered and wide corridors, hand rails, thicker mattresses, and enhanced lighting. “And the truth is that the physical plant doesn’t have to be a separate space,” Dr. Karounos said at the Society meeting. “You can insert components for the most frail and vulnerable into your current model and make a difference — for them and for everyone.” Staff and provider education that touches upon the physiology of aging, end-of-life issues, geriatric assessment, pharmacology, and delirium is key, she said, as is the integration of geriatric-focused policies and protocols for quality improvement, screening, and transitions of care. At St. Joseph’s they implemented processes for falls risk assessment, for instance. They also use the Beers criteria for inappropriate medications and the “Identification of Seniors at Risk Tool,” which assesses the level of help needed, the state of the patient’s memory and eyesight, and the degree of polypharmacy, among other things. They also implemented screening for depression and delirium and fine-tuned the Emergency Severity Index (ESI) criteria — a triage algorithm used by nurses in the ED — to better capture the severity of illness in geriatric patients. Dr. Karounos said that her geriatric ED has a “robust” medication reconciliation program that engages a pharmacist in reviewing patients who are taking five or more medications a day. “I’m a big proponent of having a pharmacist in the ED,” she said. She also touted her ED’s “two-step call-back program,” in which each patient receives a personalized phone call within 24 to 48 hours after discharge and again on days 4, 7, and 14. “We ask, how are they doing — worse or the same? Have they filled their medications? Have they set up an appointment with their PCP?” she said. “Daily, I learn of at least two or three issues from the call-back nurse, and we intervene. It’s amazing what we can do remotely after we release [them].” The geriatric ED is using hospital resources that “we had before, but almost never traditionally used before,” such as social workers, care managers, physical therapists, pharmacists, and toxicologists. “They weren’t streamlined to be used with ease in the ED,” Dr. Karounos explained. “Now, they’re almost essential.” In addition, Dr. Karounos emphasized, the geriatric ED can offer “the first touch where we can have a discussion about end-of-life care, palliative care, and goals of care,” particularly for patients from the community. She noted that “a lot of patients aren’t getting this in primary care. When we see the fourth congestive heart failure exacerbation in 2 months, it may be time to ask the patients what they want,” she said. ACEP’s new voluntary accreditation includes three levels, similar to trauma designations, with specific criteria and goals. In 2013, guidelines for optimal care in the geriatric ED were developed by ACEP in collaboration with the American Geriatrics Society, the Emergency Nurses Association, and the Society for Academic Emergency Medicine (https://www.acep.org/geda/resources/pdfs/GEDA-Guidelines.pdf). Christine Kilgore is a freelance writer in Falls Church, VA.

Post discharge issues identified by a call-back program: identifying improvement opportunities

ABSTRACTObjectives: The period following discharge from the hospital is one of heightened vulnerability. Discharge instructions serve as a guide during this transition. Yet, clinicians receive little feedback on the quality of this document that ties into the patients’ experience. We reviewed the issues voiced by discharged patients via a call-back program and compared them to the discharge instructions they had received.Methods: At our institution, patients receive an automated call forty-eight hours following discharge inquiring about progress. If indicated by the response to the call, they are directed to a nurse who assists with problem solving. We reviewed the nursing documentation of these encounters for a period of nine months. The issues voiced were grouped into five categories: communication, medications, durable medical equipment/therapies, follow up and new or ongoing symptoms. The discharge instructions given to each patient were reviewed. We retrieved data on the number of discharges from each specialty from the hospital over the same period.Results: A total of 592 patients voiced 685 issues. The numbers of patients discharged from medical or surgical services identified as having issues via the call-back line paralleled the proportions discharged from medical and surgical services from the hospital during the same period. Nearly a quarter of the issues discussed had been addressed in the discharge instructions. The most common category of issues was related to communication deficits including missing or incomplete information which made it difficult for the patient to enact or understand the plan of care. Medication prescription related issues were the next most common. Resource barriers and questions surrounding medications were often unaddressed.Conclusions: Post discharge issues affect patients discharged from all services equally. Data from call back programs may provide actionable targets for improvement, identify the inpatient team’s ‘blind spots’ and be used to provide feedback to clinicians.

Evaluation of Orthopedic Trauma Surgery Follow-up and Impact of a Routine Callback Program.

A high rate of patients lost to follow-up is a common problem in orthopedic trauma surgery. This adversely affects the ability to produce accurate clinical outcomes research. The purpose of this project was to (1) evaluate the rate of loss to follow-up at an academic level I trauma center; (2) identify the patient-reported reasons for loss to follow-up; and (3) evaluate the efficacy of a routine patient callback program. All patients who underwent surgery in the orthopedic trauma division of the University of Virginia Medical Center from April 1, 2014, to September 30, 2014, and did not complete their postoperative clinic follow-up were analyzed. The characteristics of these patients were evaluated, and the primary reason for not completing the recommended follow-up was identified. All patients were then offered additional orthopedic follow-up at the time of contact. Of the 480 patients who met the inclusion criteria, 41 (8.5%) failed to complete the recommended postoperative follow-up course. The most common reason for being lost to follow-up was feeling well and not having the need to be seen (46.3%). Only 6 (14.6%) of the 41 patients requested follow-up care at the time of contact. The lost to follow-up rate in this study, 8.5%, was considerably lower than that previously reported, but patient characteristics were consistent with those of prior studies on this subject. The low lost to follow-up rate may reflect a difference in geographic location or patient population. The patient callback program had a low yield of patients requesting additional follow-up after being contacted. [Orthopedics. 2017; 40(2):e312-e316.].

Evaluating the patient-perceived impact of clinical pharmacy services and proactive follow-up care in an ambulatory chemotherapy unit.

Purpose To evaluate the patient-perceived impact of delivery of clinical pharmacy services, including a proactive follow-up program, on patient understanding, satisfaction, and toxicity management. Methods Patients who had received clinical pharmacy services at their initial chemotherapy treatment were identified and asked to complete a 20-point survey at the second or subsequent treatment. The services that the survey evaluated consist of face-to-face education during the first treatment and proactive telephone follow-up 3 to 7 days later. Results A total of 107 of the 112 respondents (95.5%) indicated that the time with the pharmacist at the first treatment was worthwhile and 92.6% of respondents reported that the interaction with the pharmacist increased their understanding of the medication regimen. Of the 113 respondents, the majority was either "Very Satisfied" or "Satisfied" with the time the pharmacist spent with them (94.7%), and the pharmacist's ability to answer their questions (92.9%). In addition, survey results indicate that the clinical pharmacy input provided in the pharmacist call-back program is valuable, with 92.6% of the 82 respondents indicating that this service is worthwhile, and 91.4% of 93 respondents stating that the pharmacist input helped them to manage side-effects at home. Conclusions Survey results indicate that patients value clinical pharmacy services in the ambulatory oncology chemotherapy setting. These services contribute to improve patient understanding of the medication regimen, a high level of patient satisfaction, and self-management of treatment-related toxicities. These results support the provision of clinical pharmacy services and proactive follow-up programs in ambulatory chemotherapy units.

Oncology medical home: Payer return on investment (ROI).

e17582 Background: CareFirst BlueCross BlueShield (CFBCBS) partnered with Cardinal Health Specialty Solutions (CHSS) to launch the first cancer clinical pathway in the United States in August 2008. Due to the early success of the program with regard to savings and physician participation and compliance, CFBCBS and CHSS piloted an oncology medical home program in January 2011 with the hope of further decreasing cancer care costs while continuing consistency and quality of care. We analyzed payer ROI after year +1 of the medical home program. Methods: The medical home program offered a new physician reimbursement model that shifted the source of revenue from margin on drug sales to cognitive services allowing physicians to focus on optimal patient care without the financial incentive to prescribe chemotherapy. Physicians were encouraged to commit to an intensive continuous quality improvement (CQI) program, which included an end-of-life initiative and a post chemotherapy nurse call-back program that would lower costs by decreasing emergency room and hospital admissions. Physicians participating in the first CFBCBS pathway program were eligible to join the medical home program; physicians who chose not to join made up the control group. Data were collected from April 2010 to March 2012. Medical home ROI was calculated by subtracting the total weighted cost per patient for the medical home group from the total risk-adjusted cost per patient for the control group multiplied by the total number of patients in the medical home program. Results: Fourteen practices (31 physicians, 478 patients) joined the medical home program. The control group was comprised of 39 practices (103 physicians, 2031 patients). Total weighted cost per patient for the medical home program for year +1 was $26,702. Risk-adjusted cost per patient for the control group for year +1 was $30,670. The medical home program provided a gross savings of $2,016,868 compared to the first CFBCBS pathways program. Conclusions: Significant savings can be achieved in a provider group already compliant with a mature pathways program. A CQI program can directly and favorably impact patient outcomes and ROI via presumed reduction in emergency room and hospital admissions.

Comparison of Complication Rates of Implantable Venous Access Devices: Percutaneous Versus Cephalic Vein Cut-down Techniques

abdominal vascular surgery. A total of 388 patients were identified in the year prior to (266) and the year after (122) the intervention was initiated. Thirty-day readmission rates, emergency department (ED) visit rates, and early clinic visit rates (defined as a clinic visit less than 14 days postdischarge) were calculated and compared between the preand postintervention periods. Major demographic and comorbidities were then used to create a risk-adjusted logistic regression model examining the effect of the interventions on the outcomes. Results: Preintervention 30-day readmission rates were 9.8%, compared to 9.0% after the intervention (P 1⁄4 .81). The most common reason for readmission were infectious/wound-related (40.5%), and the incidence did not differ between preand postintervention time periods; additionally, patients with a positive screen for wound concerns at discharge were more likely to be readmitted (P 1⁄4 .04). Postoperative ED visit rates were identical in the postintervention group as compared to the preintervention group, as were the reasons for presentation. Risk-adjusted logistic regression models bore these trends out, though none reached statistical significance. Conclusions: A callback program did not reduce readmissions or direct patients to clinic rather than the ED in a population of patients undergoing major vascular surgery. A focused process for postoperative wound management may yield the highest decrease in readmissions.

A Focused Callback Program Does Not Decrease Readmissions After Vascular Surgery

A Focused Callback Program Does Not Decrease Readmissions After Vascular Surgery

The challenge of embracing a smoke-free lifestyle: a neglected area in smoking cessation programs

Relapse prevention theory and practice has focussed on teaching coping skills to deal with withdrawal and temptations to relapse with the result that treatments appear to be effective in reducing relapse over the short term, but not over the longer term. Once cravings subside ex-smokers face a further task of adjusting to a smoke-free lifestyle that involves learning to think and act like a non-smoker. To highlight this task, we operationalized a new conceptual framework that describes three tasks of quitting (the 3Ts): (i) making a quit attempt; (ii) learning to effectively deal with cravings and withdrawal; and (iii) adapting to a smoke-free lifestyle. This was introduced to the Quitline service in Victoria, Australia, in preparation for a randomized controlled trial aimed at testing whether a program of four to six extra callbacks could help ex-smokers with the third task and as a result reduce rates of relapse compared with Quitline's standard callback program. This paper describes the conceptual framework (focussing on the third task) and initial reactions to it from both Quitline advisors and callers. The conceptual framework is now integrated in the service and appears to have changed the way Quitline operates and the apparent expectations of its clients.

Changing Team Practice: Applying Evidence-Based Brain Injury Guidelines to Clinical Practice

Background: Trauma teams strive to provide care based on best practice. Examining the outcomes of patients sustaining severe traumatic brain injury (TBI) at our trauma center from 1994–1997, we discovered that at 6 months, 43% of the patients had expired and 30% sustained severe disability. The outcomes were consistent with some studies published on TBI in the 1980s and early 1990s. Research in the past decade on resuscitation efforts and new technology for monitoring the effects of secondary brain injury has produced improved outcomes in managing these patients. In 1995, evidence-based clinical guidelines for treating severe TBI were published recommending changes in the care of these patients. The guidelines challenged hospitals to evaluate their care practices and examine the clinical outcomes of this high-risk group. Approach: Motivated by the new practice recommendations and the potential for impacting patient outcomes, the neuro clinical nurse specialist (CNS) formed a multidisciplinary team to begin the process of performance improvement. Patient management practices were examined and relevant research evaluated. The team melded the national guidelines and supporting literature into hospital-based clinical guidelines with a series of care algorithms directing the care of these patients from admission, through the operative period, to the intensive care (ICU) phase. Prospective data were collected, and care patterns were analyzed on an annual basis. The team reconvened as needed every 12 to 18 months to discuss issues, review new literature, and alter the clinical guidelines. A vital issue emerged in 2000, which was brought to the neuro CNS by several families. Although liberal family presence was supported in the ICU, this practice was not present on the floor or rehab areas. A team of practitioners and former patients and families collaborated in August of 2000 exploring the patient-family experiences during the hospitalization. Supporting evidence-based nursing literature was reviewed, which led to the adoption of family-centered care throughout patients' hospitalization. Findings: Seven years after integrating these changes, the 6-month outcomes have improved dramatically: 72.1% showed good outcome/moderate disability, 13.6% showed severe disability to persistent vegetative state, and 14.3% died. In addition, families have become a vital force in our team's care. With key hospital team members, the families have developed a TBI family manual and formed a “call-back program” to provide support to new TBI families. The TBI families have donated more than $3 million in gifts/money to support the program. Discussion: This presentation will utilize a performance improvement approach revealing the actions used by the team to apply evidence-based guidelines and literature to the clinical setting. Statistical analysis using an ordinal regression model will provide outcome data emphasizing the positive aspects of applying evidence-based guidelines/literature to practice.

Implementation of a telephone callback service for ambulatory oncology patients

Introduction. A pilot project was established at the Cross Cancer Institute pharmacy to assess the feasibility of implementing a patient callback program to determine which patients would benefit from a callback and the impact a callback service would have on the workload of the pharmacy department. Program description/development/implementation/evaluation. A pharmacy student conducted the pilot project over a 14-week time period. Four categories of patients were selected for inclusion in the pilot. The student approached patients at the time of medication pick-up to receive verbal permission to be included in the callback program. A standardized callback form was utilized to record medication information and any recommendations made. Data were collected on the numbers of patients in each category with questions or concerns as this was felt to be indicative of patients who would most benefit from a callback. The total time spent making the telephone calls was recorded. Over the eight-week period, 530.5 minutes were spent making the telephone calls with the average length of call being 3.27 minutes. Discussion/conclusion. The student researcher proposed that three patient groups would benefit from receiving a callback: new patients or patients on new medications; elderly patients; and patients with specific disease-drug combinations. The project also provided an estimate of pharmacist time required to implement such a service and it was concluded that implementation could occur with minimal disruption to workflow.

An emergency department-based pneumococcal vaccination call-back program

An emergency department-based pneumococcal vaccination call-back program